Trends in Cholesterol Screening and Awareness of High Blood Cholesterol
--- United States, 1991--2003

High blood cholesterol (HBC) (i.e., total cholesterol
>240 mg/dL) is a major risk factor for heart disease, the leading
cause of death in the United States (1). As a result, public health agencies and their partners have attempted to reduce the prevalence of HBC through screening and by increasing public awareness of HBC and strategies for reducing it. A national
health objectives of Healthy People 2010 is to increase to 80% the proportion of adults aged
>20 years who have been screened for HBC within the preceding 5 years
(2). For this report, data from the Behavioral Risk Factor Surveillance System
(BRFSS) collected during 1991--2003 were analyzed to
examine trends in the percentage of adults screened for HBC and
the percentage of those screened who were told they had HBC. The findings indicated that both percentages increased during 1991--2003 but that few states had achieved the
national health objective for screening. Further emphasis on
cholesterol screening is needed, particularly among Hispanic and Asian/Pacific Islander populations and young adults.

BRFSS is a state-based, random-digit--dialed telephone surveillance system that samples the noninstitutionalized,
U.S. civilian population aged >18 years. For this report, CDC analyzed BRFSS data from 1991, 1993, 1995, 1997, 1999,
2001,
and 2003 for 1,027,793 persons aged >20 years. Response rates for BRFSS surveys ranged from 71.4% in 1993 to 51.1%
in 2001 (3).Survey participants were asked whether they had ever had a blood cholesterol screening and, if so, how long it had been since their last screening. Those who reported having ever been screened were asked whether they had ever been told by
a health-care professional that they had HBC. Data were weighted to account for age, race/ethnicity, and sex distributions of
the population in each state. Statistical software was used to account for the complex sampling design. The results were age-standardized to the 2000 U.S. standard population
(4). Percentage change was calculated as the 2003 prevalence minus
the 1991 prevalence divided by the 1991 prevalence multiplied by 100.

During 1991--2003, the prevalence of cholesterol screening during the preceding 5 years and the percentage of
persons screened who were told they had HBC increased overall and among all age, sex, and racial/ethnic groups (Table 1). The percentage of those screened within 5 years increased from 67.6% (95%
confidence interval [CI] = 67.2--68.1) in 1991 to 73.1%
(CI = 72.7--73.4) in 2003. Although the prevalence of cholesterol screening within 5 years was higher among
women than men in all years represented, the percentage change in prevalence was smaller for women than men. In 2003, the prevalence of cholesterol screening was lowest among Hispanics (65.5%; CI = 64.1--67.0) and Asians/Pacific Islanders (69.6%; CI = 66.9--72.4). The largest percentage changes in prevalence of cholesterol screening were among
American Indians/Alaska Natives and non-Hispanic blacks. The overall percentage of those screened who had been told they had HBC increased from 25.3% (CI = 24.7--25.8) in 1991 to 31.1% (CI = 30.7--31.5) in 2003. The percentage change among
men told they had HBC was more than twice that among women. The percentage of those screened who were told they had
HBC was higher in all racial/ethnic groups in 2003 than in 1991, with the greatest increase observed among Hispanics. Similarly, reporting of HBC increased among all age groups, with the largest percentage change in prevalence among those aged >65 years.

In 46 states and the District of Columbia (DC), the prevalence of screening increased from 1991 to 2003, with
percentage change ranging from 0.3% in Iowa to 17.5% in Kentucky (Table 2). However, by 2003, only DC and Massachusetts
had achieved the Healthy People 2010 objective for cholesterol screening, with rates of 80.2% and 80.6%, respectively. The proportion of screened adults who had been told they had HBC increased in 44 states and DC, with increases ranging
from 1.1% in Vermont to 47.5% in DC (Table 3).

Editorial Note:

The findings in this report indicate that the overall percentage of adults who had had their
cholesterol checked during the preceding 5 years increased during 1991--2003. However, in most states, increases in screening were moderate; by 2003, only DC and Massachusetts had achieved the
Healthy People 2010 objective of 80% screening
prevalence. Among those persons who had ever undergone cholesterol screening, the percentage told that they had HBC
also increased during 1991--2003. The largest increase in the prevalence of HBC screening occurred during 1999--2001 (5.1%), and in most states, the prevalence of screening continued to increase during 2001--2003.

The overall increase in cholesterol screening might have been attributable, in part,
to1)implementation of state heart-disease
and stroke-prevention programs by CDC beginning in 1998 (5); 2) release, in 2000, of Healthy People
2010, with the objective to increase the proportion of adults who have had their blood cholesterol checked during the preceding 5 years (2); and 3) publication of the National Cholesterol Education Program Adult Treatment Panel (ATP) II (1993) and ATP
III (2001) reports, which updated clinical guidelines for cholesterol testing and management
(6,7). In addition, the large increase in prevalence of screening among American
Indians/Alaska Natives might be the result of a campaign by the Indian
Health Service to improve cholesterol screening, particularly among persons at high risk for cardiovascular disease, including
those with diabetes (JM Galloway, MD, Indian Health Service, personal communication, 2004).

The increase in percentage of persons ever screened who were told that they had HBC might reflect either an
increased prevalence of cholesterol screening or an increase in the prevalence of HBC in the population. However, data based
on actual serum cholesterol levels indicate that the percentage of the U.S. population aged
>20 years with HBC decreased slightly between the 1988--1994 and 1999--2002 National Health and Nutrition Examination Surveys (8).

The findings in this report are subject to at least two limitations. First, BRFSS data are based on respondent
self-reports; respondents might have been unaware, forgotten, or not been told that they had been screened for cholesterol or had
HBC, resulting in an underestimation of the prevalence of screening and HBC. Second, BRFSS excludes households
without telephones.

HBC is one of the major modifiable risk factors for heart disease and stroke. One approach to reducing blood
cholesterol levels has been to increase public awareness and reinforce educational messages about the risks of HBC
(5,6,9). Cholesterol levels can be reduced through dietary changes (e.g., reduced intake of saturated fats and dietary cholesterol), increased physical activity, and drug treatment
(7). Although substantial progress has been made in reducing cholesterol
levels since the mid-1980s (9), an increased emphasis on cholesterol screening is necessary if more states are to achieve
objectives set forth in Healthy People 2010. The public health community and health-care systems should emphasize cholesterol screening of young adults and Hispanic and Asian/Pacific Islander populations to meet the national health
objective and the overall Healthy People
2010 goal of eliminating health disparities.

Acknowledgment

This report is based, in part, on contributions by A Tsai, PhD, Minnesota Dept of Health.

National Cholesterol Education Program. Second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel II). Circulation 1994;89:1333--445.

National Cholesterol Education Program. Executive summary of the third report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III). JAMA 2001;285:2486--97.

National Center for Health Statistics. Health, United States, 2004 with chartbook on trends in the health of Americans. Hyattsville, MD:
US Department of Health and Human Services, CDC, National Center for Health Statistics; 2004.

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